Clinical Geriatrics

More than 1.5 million Americans are injured every year by drug errors in various settings, including nursing homes. The Institute of Medicine (IOM), in its most recent report, evaluated medication errors in a broad range of settings, and finding tremendous room for improvement.¹ In the report, the IOM states that at least one-quarter of all medication-related injuries are preventable. Gurwitz et al^2,3estimated that 800,000 preventable medication-related injuries occur annually in nursing homes across the country.

Most of the “medication errors” in long-term care (LTC) settings, as reported in the IOM report, are related to prescribing and monitoring of medications. However, in the definition used for the nursing home survey process, errors related to prescribing are not considered medication errors. As a result, we end up with varying definitions of what qualify as medication errors. We should consider broadening the LTC definition to include the scope that the IOM and others consider it to be—that is, errors related to prescribing, administering, and monitoring of medications. Medicare Part D creates opportunities and challenges in working to reduce the number of medication-related errors, especially in the LTC setting.

BEERS CRITERIA
An opportunity for such an improvement exists with the use of the Beers Criteria. In 1997, the noted geriatrician Dr. Mark Beers developed and published the Beers Criteria.⁴ This outlined explicit criteria for use in prescribing medications for older patients, and identified several commonly used drugs that should be considered potentially inappropriate for use in the elderly. The Centers for Medicare & Medicaid Services adopted the criteria as part of the nursing home regulations. More recently, the criteria has been revised to take into account information available since the original publication.⁵

The Medicare prescription drug benefit offers an opportunity for incorporation of the Beers Criteria into the development of formularies and utilization measures to further ensure appropriate prescribing for older patients. Unfortunately, few prescription drug plans to date have utilized the Beers Criteria explicitly in either their formulary design or utilization management tools. Still, a great opportunity exists for incorporating these criteria to ensure more appropriate use of medications in the elderly.

TRANSITIONS IN CARE
One major area where medication errors occur in LTC is during the transition from one care setting to another.^6-9 The transitions from the nursing home to other settings are times of high risk for adverse effects due to prescribing or transcription errors. Excluding wrong-time errors, omission of an ordered medication is generally the most common type of drug administration error in nursing homes.

In this instance, Medicare Part D only serves to add to the confusion since transition in settings of care may mean transitions in prescription drug coverage administration. With this change in coverage, medications are often required to be changed from a nonformulary medication to one covered under the plan.

MED PASSES
Another area in the nursing home where medication errors occur is during the medication administration, or “med pass.” Since a typical medication pass in LTC usually exceeds 2 hours, it may be impossible for a nurse to deliver all medications within 1 hour of the scheduled time, making “wrong-time” errors predictably high in this setting.

Medicare Part D makes this situation increasingly more likely because prescription drug plans often restrict access to extended-release medications, while forcing the use of short-acting ones. This can result in more medications being administered during each med pass, with the likelihood of a delay in medication administration increasing.